Oregon's program to improve care for those with advanced illness highlighted in JAMA

Oregon's groundbreaking Physician Orders for Life Sustaining Treatment program (POLST) is featured in the latest edition of the Journal of The American Medical Association. The program, which was created by health care professionals two decades ago in an effort to ensure the wishes of those with advanced illness are followed, has now spread to 34 states around the country. The program's key component is an order form that provides clear instruction about the patient's health care preferences to health professionals, such as paramedics and emergency room physicians, when a patient cannot communicate these wishes themselves. The form allows patients to request that they receive or refrain from certain measures such as CPR or intensive care. In addition, Oregon's program includes a registry that offers 24-hour access to emergency workers when the printed form cannot be located.

The JAMA article highlights the latest research to gauge the impacts of the program. That data revealed:

25,142 people were enrolled in Oregon's registry during the first year of operation.

86 percent of patients in the POLST program are 65 or older.

28 percent wished to receive CPR if needed.

72 percent had a "Do Not Resuscitate" order.

50 percent of patients who had a DNR order wanted to be hospitalized.

"Our study shows that resuscitation is not the most important question for people with advanced illness and frailty," said Susan Tolle, M.D., director of the Center for Ethics in Health Care at Oregon Health & Science University and senior author on the study. OHSU administers both the program and the registry. "Not only is CPR unlikely to be successful in patients with advanced illness, but knowing that the patient has a DNR order does not predict what other treatments they want or do not want. Half of patients with a DNR order wanted to return to the hospital and half did not. POLST orders for scope of treatment clarify which patients want to be hospitalized and whether they would want intensive care in a time of crisis."

"The POLST program creates a system that has been shown to have advantages over traditional advance directives and do-not-resuscitate orders by providing a more comprehensive set of medical orders based on patient preferences and ensuring that patients receive the medical treatment they want with a high degree of accuracy," added Alvin H. Moss, M.D., director of the West Virginia Center for End-of-Life Care, which oversees the Physician Orders for Scope of Treatment (POLST) program, a program comparable to Oregon's POLST program, and the WV e-Directive Registry. "The Oregon POLST registry is the final step in completing the system and makes those orders available to treating health care providers in an emergency."

One of the important aspects of the POLST program is its ability to launch important discussions among patients, their loved ones and health care professionals. When these discussions occur in the early stages of advanced illness for frailty, patients can share their wishes in case they are unable to communicate in a time of crisis. In addition, the program offers families some peace of mind because when a patient fills out a POLST form, the burden of family members who previously could only speculate on their loved one's wishes, need not do so anymore.

"One of my colleagues, a rural doctor, taught me not to start my conversations about goals of care with code status," explained study author Erik Fromme M.D., a palliative care specialist at OHSU. "Instead, he said, it should be the last question you talk about. Too often in health care the conversation begins and ends with resuscitation, when it would be much more helpful to know what kind of care a patient wants before they arrest. Our data, and programs like Oregon's support the wisdom of this approach."